Clinician's Notes Ambulatory Setting v1.1

[Abdur Rehman]

Hello, 

We are still confused in Clinician Notes (170.315(f)(7) Healthcare Surveys) for Ambulatory Setting v1.1. Is this enough to give an option to add Loinc code in Clinician Notes to full fill the requirements?

For reference point please find the attached image. 

Thanks, 

Abdur Rehman

[Brian Gugerty]

Mr. Rehman,

 

Thank you for this follow up question. Here is our response:

 

The example of ‘Targeted history and physical note’ with a LOINC document code of 34138-8 is intended as an example and illustration of different types of documents that are acceptable to us. In addition to ‘Targeted history and physical note’ a desired set of notes includes clinical notes which may be practically/locally referred to as Triage Notes, Intake Notes, History of Present Illness Notes, Clinical Impression Notes, and Discharge Notes.

 

The contents of these clinical notes and not just the identifying LOINC code is also desired. We expect to receive the note content as an external document, referenced within the NHCS C-CDA.

 

 

Regards,

 

Brian 

[lind...@allscripts.com]

Dear Brian

From DHCSTestData1_0and1_1.xlsx, the Clinical Note is indicated as [MAY] for all 3 types of HCS IG.  Does it mean this is an optional requirement and not mandatory for MU3 Certification?

Regards

Linda

[lind...@allscripts.com]

RE: Triage Notes, Intake Notes, History of Present Illness Notes, Clinical Impression Notes, and Discharge Notes.

 Also, if mandatory requirement, can you please advise which CDA template each desired clinical notes needs to use?  

Thank you

[Brian Gugerty]

Yes.

Brian Gugerty, DNS, RN

Senior Service Fellow, Division of Health Care Statistics, CDC/NCHS

[lind...@allscripts.com]

Thank you for clarification. My team has follow up questions.

1. Can we use CCDA CCD or Unstructured Document V3 templates for Triage Notes, Intake Notes, History of Present Illness Notes, Clinical Impression Notes,Discharge notes, or does each note has a specific CCDA Template we need to use?

2. How should we transmit this external document CCDA to CDC? Should we send it in the same transmission with referenced Health Care Survey CDA, or can it be in separate transmissions?

Thank you again. 

Linda

[Brian Gugerty]

Linda,

 

Thank you for this question.

 

This template represents relevant clinical (e.g., physicians', nurses', P.A.s', N.P.s' and C.N.M.s') notes for this visit, such as Triage, Intake, History of Present Illness, Clinical Impression and Discharge. If the current visit is the result of a referral, the referral document can be referenced using this template.

These notes or documents can be CDA documents or they can be other types of documents such as PDF.

The following (non-exhaustive) table lists some LOINC code examples for relevant document types:

Document type	LOINC code
History of Present Illness Narrative	10164-2
Evaluation and Plan Note	51847-2
Evaluation Note	51848-0
Reason for Visit Narrative	29299-5
Referral Note	57113-1

 

 

Regards,

Brian

-------------------------------------------------------------

Brian Gugerty, DNS, RN

Senior Service Fellow, Division of Health Care Statistics, CDC/NCHS

[Brian Gugerty]

Linda, 

Thank you for these questions. 

 

1.     Yes you can use CCDA CCD or Unstructured Document V3 templates for Triage Notes, Intake Notes, History of Present Illness Notes, Clinical Impression Notes and Discharge notes.  No, each note type does not have to be a specific template.

2.     This is from the HL7 CDA National Health Care Surveys Implementation Guide,  1.1 version, vol 2 pg 221: 

 

“Where it is necessary to reference an external clinical document, the External Document Reference template can be used to reference this external document. However, if the containing document is replacing or appending to another document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument.”

 

Therefore, you can send the external clinical document in the same transmission with referenced Health Care Survey CDA. 

 

Regards,

Brian

-------------------------------------------------------------

Brian Gugerty, DNS, RN

Senior Service Fellow, Division of Health Care Statistics, CDC/NCHS

[Brian Gugerty]

Linda,

Thank you for these questions.

 

1.     Yes you can use CCDA CCD or Unstructured Document V3 templates for Triage Notes, Intake Notes, History of Present Illness Notes, Clinical Impression Notes and Discharge notes.  No, each note type does not have to be a specific template.

2.     This is from the HL7 CDA National Health Care Surveys Implementation Guide,  1.1 version, vol 2 pg 221: 

 

“Where it is necessary to reference an external clinical document, the External Document Reference template can be used to reference this external document. However, if the containing document is replacing or appending to another document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument.”

 

Therefore, you can send the external clinical document in the same transmission with referenced Health Care Survey CDA. 

 

Regards,

Brian

-------------------------------------------------------------

Brian Gugerty, DNS, RN

Senior Service Fellow, Division of Health Care Statistics, CDC/NCHS

On Wednesday, September 7, 2016 at 1:16:53 AM UTC-4, lind...@allscripts.com wrote: